Month: June 2022

When you first learned the facts about pregnancy — from a parent, perhaps, or a friend — you probably didn’t learn that up to one in three ends in a miscarriage.

What causes miscarriage? How is it treated? And why is appropriate health care for miscarriage under scrutiny — and in some parts of the US, getting harder to find?

What is miscarriage?

Many people who come to us for care are excited and hopeful about building their families. It’s devastating when a hoped-for pregnancy ends early.

Miscarriage is a catch-all term for a pregnancy loss before 20 weeks, counting from the first day of the last menstrual period. Miscarriage happens in as many as one in three pregnancies, although the risk gradually decreases as pregnancy progresses. By 20 weeks, it occurs in fewer than one in 100 pregnancies.

What causes miscarriage?

Usually, there is no obvious or single cause for miscarriage. Some factors raise risk, such as:

• Pregnancy at older ages. Chromosome abnormalities are a common cause of pregnancy loss. As people age, this risk rises.
• Autoimmune disorders. While many pregnant people with autoimmune disorders like lupus or Sjogren’s syndrome have successful pregnancies, their risk for pregnancy loss is higher.
• Certain illnesses. Diabetes or thyroid disease, if poorly controlled, can raise risk.
• Certain conditions in the uterus. Uterine fibroids, polyps, or malformations may contribute to miscarriage.
• Previous miscarriages. Having a miscarriage slightly increases risk for miscarriage in the next pregnancy. For instance, if a pregnant person’s risk of miscarriage is one in 10, it may increase to 1.5 in 10 after their first miscarriage, and four in 10 after having three miscarriages.
• Certain medicines. A developing pregnancy may be harmed by certain medicines. It’s safest to plan pregnancy and receive pre-pregnancy counseling if you have a chronic illness or condition.

How is miscarriage diagnosed?

Before ultrasounds in early pregnancy became widely available, many miscarriages were diagnosed based on symptoms like bleeding and cramping. Now, people may be diagnosed with a miscarriage or early pregnancy loss on a routine ultrasound before they notice any symptoms.

How is miscarriage treated?

Being able to choose the next step in treatment may help emotionally. When there are no complications and the miscarriage occurs during the first trimester (up to 13 weeks of pregnancy), the options are:

Take no action. Passing blood and pregnancy tissue often occurs at home naturally, without need for medications or a procedure. Within a week, 25% to 50% will pass pregnancy tissue; more than 80% of those who experience bleeding as a sign of miscarriage will pass the pregnancy tissue within two weeks.

What to know: This can be a safe option for some people, but not all. For example, heavy bleeding would not be safe for a person who has anemia (lower than normal red blood cell counts).

Take medication. The most effective option uses two medicines: mifepristone is taken first, followed by misoprostol. Using only misoprostol is a less effective option. The two-step combination is 90% successful in helping the body pass pregnancy tissue; taking misoprostol alone is 70% to 80% successful in doing so.

What to know: Bleeding and cramping typically start a few hours after taking misoprostol. If bleeding does not start, or there is pregnancy tissue still left in the uterus, a surgical procedure may be necessary: this happens in about one in 10 people using both medicines and one in four people who use only misoprostol.

Use a procedure. During dilation and curettage (D&C), the cervix is dilated (widened) so that instruments can be inserted into the uterus to remove the pregnancy tissue. This procedure is nearly 99% successful.

What to know: If someone is having life-threatening bleeding or has signs of infection, this is the safest option. This procedure is typically done in an operating room or surgery center. In some instances, it is offered in a doctor’s office.

If you have a miscarriage during the second trimester of pregnancy (after 13 weeks), discuss the safest and best plan with your doctor. Generally, second trimester miscarriages will require a procedure and cannot be managed at home.

Red flags: When to ask for help during a miscarriage

During the first 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• heavy bleeding combined with dizziness, lightheadedness, or feeling faint
• fever above 100.4° F
• severe abdominal pain not relieved by over-the-counter pain medicine, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Please note: ibuprofen is not recommended during pregnancy, but is safe to take if a miscarriage has been diagnosed.

After 13 weeks of pregnancy: Contact your health care provider or go to the emergency department immediately if you experience

• any symptoms listed above
• leakage of fluid (possibly your water may have broken)
• severe abdominal or back pain (similar to contractions).

How is care for miscarriages changing?

Unfortunately, political interference has had significant impact on safe, effective miscarriage care:

• Some states have banned a procedure used to treat second trimester miscarriage. Called dilation and evacuation (D&E), this removes pregnancy tissue through the cervix without making any incisions. A D&E can be lifesaving in instances when heavy bleeding or infection is complicating a miscarriage.
• Federal and state lawsuits, or laws banning or seeking to ban mifepristone for abortion care, directly limit access to a safe, effective drug approved for miscarriage care. This could affect miscarriage care nationwide.
• Many laws and lawsuits that interfere with miscarriage care offer an exception to save the life of a pregnant patient. However, miscarriage complications may develop unexpectedly and worsen quickly, making it hard to ensure that people will receive prompt care in life-threatening situations.
• States that ban or restrict abortion are less likely to have doctors trained to perform a full range of miscarriage care procedures. What’s more, clinicians in training, such as resident physicians and medical students, may never learn how to perform a potentially lifesaving procedure.

Ultimately, legislation or court rulings that ban or restrict abortion care will decrease the ability of doctors and nurses to provide the highest quality miscarriage care. We can help by asking our lawmakers not to pass laws that prevent people from being able to get reproductive health care, such as restricting medications and procedures for abortion and miscarriage care.

About the Authors

Sara Neill, MD, MPH, Contributor

Dr. Sara Neill is a physician-researcher in the department of obstetrics & gynecology at Beth Israel Deaconess Medical Center and Harvard Medical School. She completed a fellowship in complex family planning at Brigham and Women's Hospital, and … See Full Bio View all posts by Sara Neill, MD, MPH

Scott Shainker, DO, MS, Contributor

Scott Shainker, D.O, M.S., is a maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center (BIDMC). He is also a member of the faculty in the Department of Obstetrics, … See Full Bio View all posts by Scott Shainker, DO, MS

Everything is connected. You’ve probably heard that before, but it bears repeating. Below are five ways to boost both your individual health and the health of our planet — a combination that environmentalists call co-benefits.

How your health and planetary health intersect

Back in 1970, Earth Day was founded as a day of awareness about environmental issues. Never has awareness of our environment seemed more important than now. The impacts of climate change on Earth — fires, storms, floods, droughts, heat waves, rising sea levels, species extinction, and more — directly or indirectly threaten our well-being, especially for those most vulnerable. For example, air pollution from fossil fuels and fires contributes to lung problems and hospitalizations. Geographic and seasonal boundaries for ticks and mosquitoes, which are carriers of infectious diseases, expand as regions warm.

The concept of planetary health acknowledges that the ecosystem and our health are inextricably intertwined. Actions and events have complex downstream effects: some are expected, others are surprising, and many are likely unrecognized. While individual efforts may seem small, collectively they can move the needle — even ever so slightly — in the right direction.

Five ways to improve personal and planetary health

Adopt plant-forward eating.

This means increasing plant-based foods in your diet while minimizing meat. Making these types of choices lowers the risks of heart disease, stroke, obesity, high blood pressure, type 2 diabetes, and many cancers. Compared to meat-based meals, plant-based meals also have many beneficial effects for the planet. For example, for the same amount of protein, plant-based meals have a lower carbon footprint and use fewer natural resources like land and water.

Remember, not all plants are equal.

Plant foods also vary greatly, both in terms of their nutritional content and in their environmental impact. Learning to read labels can help you determine the nutritional value of foods. It’s a bit harder to learn about the environmental impact of specific foods, since there are regional factors. But to get a general sense, Our World in Data has a collection of eye-opening interactive graphs about various environmental impacts of different foods.

Favor active transportation.

Choose an alternative to driving such as walking, biking, or using public transportation when possible. Current health recommendations encourage adults to get 150 minutes each week of moderate-intensity physical activity, and two sessions of muscle strengthening activity. Regular physical activity improves mental health, bone health, and weight management. It also reduces risks of heart disease, some cancers, and falls in older adults. Fewer miles driven in gas-powered vehicles means cleaner air, decreased carbon emissions contributing to climate change, and less air pollution (known to cause asthma exacerbations and many other diseases).

Start where you are and work up to your level of discomfort.

Changes that work for one person may not work for another. Maybe you will pledge to eat one vegan meal each week, or maybe you will pledge to limit beef to once a week. Maybe you will try out taking the bus to work, or maybe you will bike to work when it’s not winter. Set goals for yourself that are achievable but are also a challenge.

Talk about it.

It might feel as though these actions are small, and it might feel daunting for any one individual trying to make a difference. Sharing your thoughts about what matters to you and about what you are doing might make you feel less isolated and help build community. Building community contributes to well-being and resilience.

Plus, if you share your pledges and aims with one person, and that person does the same, then your actions are amplified. Who knows, maybe one of those folks along the way might be the employee who decides what our children eat from school menus, or a city planner for pedestrian walkways and bike lanes!

About the Author

Wynne Armand, MD, Contributor

Dr. Wynne Armand is a physician at Massachusetts General Hospital (MGH), where she provides primary care; an assistant professor in medicine at Harvard Medical School; and associate director of the MGH Center for the Environment and … See Full Bio View all posts by Wynne Armand, MD

Three months into the year is a good time to recalculate if you’ve been slacking on your resolution to eat healthy. And if you’ll be leaving home base or school soon and foraging for yourself (plus or minus roommates), it’s a great time to learn about healthy, low-cost choices for your grocery list.

The basics: A weekly shop

A healthy diet is rich in vegetables, fruits, legumes (beans or lentils), whole grains, nuts, seeds, lean proteins, and low-fat dairy products. Trying to fill your cart with all of those goodies can feel overwhelming. But just think in terms of twos.

“Get two fruits and two vegetables of different colors, and two types of lean protein — such as fresh, frozen, or canned fish, chicken or lean ground turkey, or plant-based options,” suggests Nancy Oliveira, a registered dietitian and manager of the Nutrition and Wellness Service at Harvard-affiliated Brigham and Women’s Hospital.

Oliveira also recommends getting two foods in each of these categories on your weekly shopping trip:

• plant proteins, such as canned or dried beans, tofu, tempeh, veggie burgers, or unsalted nuts or seeds
• whole grains, such as whole-grain bread, whole-grain pasta, brown or black rice, quinoa, or farro
• dairy or nondairy milk items, such as nonfat Greek yogurt or cheese.

Go ahead and add one or two healthy treats or snacks, such hummus or dried apricots.

Do you need to choose organic foods?

Organic produce is grown without synthetic fertilizers and pesticides, which are linked to many health problems. While US scientists debate whether foods grown with organic fertilizers (such as animal waste) are safer for your health, other countries, including European Union nations, have banned or phased out synthetic pesticides still used in the United States.

That doesn’t mean that everything you buy must be organic. But try to stay away from conventionally grown produce with thin skins, such as strawberries, spinach, kale, peaches, and grapes. They tend to absorb more chemicals compared to produce with thick skins, such as avocados or pineapples.

The Environmental Working Group creates an annual list to help shoppers avoid high-pesticide produce, and another one that highlights the least contaminated produce.

Buying cost-conscious fresh food and staples

Healthy food, especially organic produce, has a reputation for being expensive. But it doesn’t have to be. Just do a little comparison shopping, and follow Oliveira’s tips to save money on a grocery run:

• Shop in a smaller store with fewer choices.
• Never enter a store hungry, since you might buy more than you normally would.
• Carry a shopping list and stick to it.
• Go directly to the aisles you need. Avoid browsing elsewhere, which may lead to extra purchases.
• Be flexible, have several options within your food categories, and go with sale items.
• Always check the day-old produce cart that offers perfectly edible fresh produce at 50% to 75% off regular prices.
• Buy unseasoned canned or frozen whole foods such as vegetables, chicken, or fish (salmon, sardines, tuna), which are often cheaper than fresh versions.
• Wait for sales of healthy nonperishable staples like quinoa, brown rice, whole-grain pasta, and high-fiber cereals.
• Use coupons and coupon apps.

Easy healthy snacks to reach for

Move on from easy grab-n-go snacks, which are typically processed foods. They often contain unhealthy ingredients and promote overeating. Instead, Oliveira suggests keeping healthy snacks on hand, such as:

• unsalted mixed nuts
• string cheese
• grapes and berries (rinse before eating)
• clementines, bananas, or other fruits that don’t need washing
• a rice cake with nut butter or hummus
• fat-free Greek yogurt
• a peeled hard-boiled egg.

“To save money, buy certain foods in larger amounts when possible, such as an 8-ounce bar of cheese that you slice into small cubes and store in a sealed container in the fridge,” Oliveira says.

Crowdsource shopping tips and savings

Don’t be shy about asking for shopping tips from friends and family members who’ve already developed shortcuts, and grocery store staffers who can offer insider advice.

You can also turn to apps for help. Oliveira recommends two faves:

• Mealime is a meal-planning app with simple, healthy plant-based recipes that automatically create grocery lists for the ingredients.
• List Ease creates lists for grocery runs. You can search for items to add or scan barcodes to add to lists.

“And if you prefer not to use apps, just jot down notes after a quick pantry or fridge inventory, or text yourself every time you remember something you need,” Oliveira advises. “With a little practice, you’ll quickly work out the best system for you.”

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

A simple word we all hear often — exercise — makes many people cringe. Unhappy childhood memories of school sports or gym classes, flat-out physical discomfort, guilty reluctance, or trouble finding time or pleasurable activities may help explain this. Additionally, for some people with obesity, fear of falling or injury is a high barrier to activity, recent research suggests.

That finding has important implications for health and well-being. So, how can we make movement safe and joyful for people of all weights?

Why be active?

As you may know, being physically active helps combat anxiety and depression. It prevents bone from thinning and tones muscle, helps you sleep better, lowers your blood pressure and blood sugar, and improves your cholesterol levels. It would take numerous medications to do all that routine physical activity can do for you.

Weight loss programs often incorporate exercise. Research shows that exercise helps with weight maintenance and may help with weight loss. Beyond burning calories, regular exercise also builds muscle mass. This matters because muscles are metabolically active, releasing proteins that play a role in decreasing appetite and food intake.

What does this study tell us?

The study found that many people with obesity fear injury and falling, which interferes with willingness to exercise. It followed 292 participants enrolled in an eight-week medical weight loss program in Sydney, Australia. All met criteria for obesity or severe obesity. The average age was 49; one-third of participants were male and two-thirds were female.

At the beginning of the study, participants filled out a 12-question injury perception survey. The majority reported fear of injury or falling, and believed their weight made injury more likely to occur. One-third said that their fear stopped them from exercising. The researchers also recorded weight, height, and waist circumference, and administered strength tests during the first, fourth, and last sessions.

When the study ended, the researchers found that the participants most concerned about getting injured hadn’t lost as much weight as those who did not express this fear. Those who hadn't lost as much weight also tended to have the highest scores of depression, anxiety, and sleepiness.

Fear of injury fuels a dangerous cycle

As noted, exercise is healthy at every weight: it protects your heart, lowers your blood sugar, boosts your mood, and tamps down anxiety. It also builds balance. Weight-bearing exercise such as walking prevents bone thinning.

If worries about injury or falls cause people to avoid exercise, they miss out on the balance-building, muscle-and-bone-strengthening, and mood-enhancing benefits of regular activity. They may be more likely to fall — and possibly more likely to experience fractures if they do.

Find a blend of activities that will work for you

Everyone, at every weight, needs to find ways to exercise safely, confidently, and joyfully.

• Start low and go slow. If you’re not currently active, start by simply sitting less and standing more. Try walking for two minutes every half hour. If you’re afraid of falling, try walking in place or alongside a friend or loved one who can provide security and comfort.
• Ask for guidance. Consider joining a YMCA where you can engage in supervised activities, or ask your doctor for a prescription to physical therapy to help you improve your balance and build your confidence.
• Try different activities to see what works for you. Walking is a simple, healthful activity, but it’s not the only form of activity you can try. You might enjoy swimming or water aerobics. Try pedaling a seated bike or an arm bike (upper body ergometer) that allows you to stay seated while you propel pedals with your arms instead of your feet. Adaptive activities and sports designed for people with physical limitations and disabilities are an option, too. Depending on your fitness level and interests, you might also consider dancing, biking, or anything else that gets you moving more often.

Lastly, keep in mind that many people suffer from anxiety, and a fear of falling is not insurmountable. If you’re really struggling, talk to your doctor or a mental health professional.

About the Author

Elizabeth Pegg Frates, MD, FACLM, DipABLM, Contributor

Dr. Beth Frates is a trained physiatrist and a health and wellness coach, with expertise in lifestyle medicine. She is an award-winning teacher at Harvard Medical School, where she is an assistant clinical professor. Dr. Frates … See Full Bio View all posts by Elizabeth Pegg Frates, MD, FACLM, DipABLM